Tracheostomy Care: Humidifying and Suctioning

Why is humidifying and suctioning important?

When you breathe through your mouth and nose, air is naturally warmed, moistened, and cleaned. Air coming in through a tracheostomy (trach) tube does not get moistened and cleaned. When this cool, dry air comes into the tube, it causes the lungs to make more mucus. The secretions can become thick and hard to cough up. They may block the trach tube and make it hard for you to breathe. In addition to getting enough humidity to keep secretions thin, you will also need to suction the trach tube to remove secretions. Having enough humidity and suctioning the trach tube make it less likely that the tube will become blocked. Blockages can be very dangerous and stressful. Work with your healthcare provider to learn how to manage your tracheostomy care so that you can have a normal, active life.

HUMIDIFICATION

Humidification is very important for thinning secretions so that they do not block the trach tube. Humidification is needed even in very damp climates, at least at first. Humidity in the lungs helps to protect the lining of the lungs, and it helps keep secretions thin.

How do I keep the air humidified?

Air is humidified using a humidifier or a heat moisture exchanger (HME). The HME is a device that you can wear during the day to help keep the air moist without being hooked up to a humidifier.

Before you are discharged from the hospital, your discharge planner or instructor should make arrangements with a medical supply company to get a humidifier, HME, and any other equipment you will need.

Humidifier: Several different types of humidifiers are available. They all have a water reservoir, a connecting hose, and a collar that fastens around your neck. The collar keeps a pocket of moist air at the opening of the trach tube. This type of humidifier should be used at night and at different times during the day.

Your discharge instructor or the equipment supplier will teach you how to use and clean the humidifier and how to order supplies. Usually, you will need to clean and disinfect the humidifier at least once a week, according to the supplier's instructions.

The thickness of your secretions as well as changes in your breathing rate and pattern will help you decide if you need to stay on the humidifier during the day. Faster breathing, a heavy cough, and thicker secretions mean you need to use the humidifier. If your secretions are thin, you are breathing normally, and you do not have a heavy cough, you are probably ready for the HME and normal activity.

HME (Heat Moisture Exchanger): An HME is a humidifying filter that fits onto the end of the trach tube. HMEs are also called artificial noses, filters, or T-pieces. They come in several shapes and styles. The filter may be made of gauze, foam, or a special paper. As you breathe out, the HME collects warmth and moisture. When you breathe in, the air is warmed and humidified.

Use the HME when you are awake and active and want to be free from humidifying equipment. Then, use the humidifier during meals and at night to help your lungs get more moisture. Usually a person with a new tracheostomy can start out wearing an HME for at least 1 hour at a time, 2 or 3 times a day. If the secretions do not get too thick and you seem to handle the HME well, you can start wearing the HME for a longer time. Sometimes you may need short breaks using the humidifier, and then you will be ready to use the HME again.

Disposable HMEs are meant for single use. They should be thrown away when they get clogged with mucus. If too much mucus is a problem, a reusable HME (a plastic T-piece with replaceable gauze) is a less expensive option. The plastic T-piece can be washed and disinfected many times, but the disposable HMEs cannot. You may find it helpful to use both types. For example, use a T-piece with gauze in the morning (until the amount of secretions goes down) and then use a disposable HME in the afternoon.

If you have been using an HME for a long period of time, or if it is hot and dry or windy, add a few drops of saline to the gauze to replace lost moisture. You can buy saline drops at your local drug store or pharmacy. If you are drinking plenty of fluids and have been using the humidifier, you will not need to moisten the gauze in the HME.

The best way to judge how long you can use an HME is to periodically suction the trach.

• If the secretions pass through the catheter easily, you can wear the HME for a longer period of time.
• If secretions are sluggish through the catheter, you may need to add a few drops of saline to the trach or the HME to replace evaporated moisture.
• If secretions coat the outside of the catheter or clog it, you may need to use the humidifier for at least 1/2 to 1 hour or need several drops of saline put into the trach tube, followed by suctioning until the secretions thin out.

Remember to:

• Check the HME gauze to be sure it doesn't get covered with secretions.
• Drink plenty of fluid each day. Getting plenty of fluid will help keep secretions thin.

Check with your specialist if you have questions about humidification or HMEs.

SUCTIONING

Suctioning is important to keep mucus from blocking the trach tube. It helps clear secretions and makes breathing easier.

When do I suction the tube?

Suctioning should be done whenever it is needed. Signs that you need suctioning include:

• gurgling or bubbly sounds
• coughing
• trouble breathing or very fast breathing.

Suctioning should also be done at the following set times:

• before eating (waiting until after eating may lead to vomiting)
• before and after sleep (including naps).

How often you need to suction depends on how much mucus you have and how well you are breathing.

Remember, your body is always making secretions and saliva. This is fluid that the body naturally recycles. If you suction too much, you may not have the reserve of moisture you need to wear the HME for longer periods of time.

What equipment is needed?

You will need the following equipment for suctioning:

• A suction machine with tubing
• A clean catheter (a catheter is a small tube that goes through the trach opening into the airway and removes the secretions). You need to know how long your trach tube is to know how much of the catheter you need to insert. Hold the catheter at or just above the suction depth. If the catheter is marked, hold it at 6.5 or 7.0 cm if you are going to suction 6.5 cm. For unmarked catheters, tape a small ruler to your suction machine and have your specialist mark the correct depth in centimeters and inches for you. Before you leave the hospital your discharge instructor should tell you the length of your trach tube and how far to suction.
• A rinsing solution of sterile water or saline.

You should also have access to a resuscitation bag in case of unexpected emergencies with the tracheostomy.

How do I suction the tube?

To suction the tube:

1. Wash your hands with soap and water and dry them well.
2. Pick up the catheter from the end that will be attached to the suction machine. Do not pick up the end that will go into the trach tube.
3. Connect the catheter to the suction machine tubing and turn on the machine. Be sure you know how far the catheter should go in before you begin suctioning--usually the length of the trach tube plus 1/4 inch. Hold the catheter at or just above the suction depth.
4. Gently put the catheter into the trach tube without applying suction. The catheter will follow the curve of the trach tube. Stop the catheter when you reach the premeasured length. Do not force it. If you cannot pass the catheter the specified depth, the trach tube may have a plug inside it. Add saline and try again. If you are again unsuccessful, change the tube immediately.
5. Apply suction by putting your thumb over the hole in the catheter while you gently pull the catheter back out. Gently roll the catheter between your thumb and forefinger as you pull the catheter out.

Do not suction for longer than 5 to 10 seconds at a time. If you suction longer than that, you may block oxygen from getting to your lungs.

Normal secretions are clear to white and are thin to slightly thick. If the secretions are very thick, you may need to suction several times. You should rest and breathe for at least 30 seconds before suctioning again. Put several drops of saline (not plain sterile water) down the trach and suction again. Putting saline solution down the trach and suctioning will likely cause coughing and choking. This is normal and helps to loosen secretions so that you can cough them out.

NOTE: Expert opinions vary on the use of gloves, saline, and air.

• Gloves: Some experts recommend gloves when you suction, others do not. Ask your healthcare provider if you should wear gloves. Wash your hands carefully before and after suctioning, whether you wear gloves or not.
• Saline drops: Some experts recommend putting a few drops of saline down the trach before you suction the first time. Others recommend first suctioning without saline so you can see how the secretions look. Some advise making your own saline solution while others recommend buying the saline solution. Ask your healthcare provider what you should do.
• Air: Some experts recommend giving a puff of air with a bag before and after suctioning to get oxygen into your lungs. Other experts don't feel this is necessary.

Be sure you understand the steps of suctioning and have practiced it many times before you get home.

How do I clean the suctioning equipment?

Rinse the catheter with sterile water and store it in a commercially made solution or a solution of 1 part hydrogen peroxide to 1 part sterile water. Rinse the catheter with sterile water just before using it. Clean the catheter suction machine, tubing, and any other parts that have touched the secretions regularly. The equipment supplier will tell you how and when to do this.